STATE OF NEVADA

BRIAN SANDOVAL Governor

RICHARD WHITLEY, MS Director, DHHS

STATE OF NEVADA

CODY L. PHINNEY, MPH Administrator, DPBH

JOHN DIMURO, D.O., MBA Chief Medical Officer

DEPARTMENT OF HEALTH AND HUMAN SERVICES DIVISION OF PUBLIC AND BEHAVIORAL HEALTH BUREAU OF HEALTH CARE QUALITY AND COMPLIANCE

727 Fairview Dr., Suite E, Carson City, NV 89701 Telephone: 775-684-1030, Fax: 775-684-1073 dpbh.

NOTICE OF NONCRIMINAL JUSTICE APPLICANT'S RIGHTS, CONSENTS AND SELF DISCLOSURE OF CRIMINAL HISTORY

FINGERPRINT BACKGROUND WAIVER -NOTICE OF NONCRIMINAL JUSTICE APPLICANT'S RIGHTS As an applicant who is the subject of a Federal Bureau of Investigation (FBI) fingerprint-based criminal history record check for a noncriminal justice purpose you have certain rights which are discussed below.

1. You must be notified by (enter name of requesting agency) Division Public and Behavioral Health that your fingerprints will be used to check the criminal history records of the FBI and the State of Nevada.

2. If you have a criminal history record, the officials making a determination of your suitability for the job, license or other benefit for which you are applying must provide you the opportunity to complete or challenge the accuracy of the information in the record. You may review and challenge the accuracy of any and all criminal history records which are retu rned to the submitting agency. The proper forms and procedures will be furnished to you by the Nevada Department of Public Safety, Records Bureau upon request. If you decide to challenge the accuracy or completeness of your FBI criminal history record, Title 28 of the Code of Federal Regulations, Section 16.34, provides for the proper procedure to do so:

16.34 - Procedure to obtain change, correction or u pdating of identification records. If after reviewing his/her identification record, the subject thereof believes that it is incorrect or incomplete in any respect and wishes changes, corrections or updating of the alleged deficiency, he/she should make application directly to the agency which contributed the questioned information. The subject of a record may also direct his/her challenge as to the accuracy or completeness of any entry on his/her record to the FBI, Criminal Justice Information Services (CJIS) Division, ATTN: SCU, Mod. D-2, 1000 Custer Hollow Road, Clarksburg, WV 26306. The FBI will then forward the challenge to the agency which submitted the data requesting that agency to verify or correct the challenged entry. Upon the receipt of an official communication directly from the agency which contributed the original information, the FBI CJIS Division will make any changes necessary in accordance with the information supplied by that agency.

3. Based on 28 CFR ? 50.12 (b), officials making such determinations should not deny the license or employment based on information in the record until the applicant has been afforded a reasonable time to correct or complete the record or has declined to do so.

Public Health: Working for a Safer and Healthier Nevada

4. You have the right to expect that officials receiving the results of the fingerprint-based criminal history record check will use it only for authorized purposes and will not retain or disseminate it in violation of federal or state statute, regulation or executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy Compact Council.

5. I hereby authorize (enter name of requesting agency) Division Public and Behavioral Health, to submit a set of my fingerprints to the Nevada Department Public Safety, Records Bureau for the purpose of accessing and reviewing State of Nevada and FBI criminal history records that may pertain to me. In giving this authorization, I expressly understand that the records may include information pertaining to notations of arrest, detainments, indictments, information or other charges for which the final court disposition is pending or is unknown to the above referenced agency. For records containing final court disposition information, I understand that the release may include information pe1taining to dismissals, acquittals, convictions, sentences, correctional supervision information and information concerning the status of my parole or probation when applicable.

6. I hereby release from liability and promise to hold harmless u nder any and all causes of legal action, the State of Nevada, its officer(s), agent(s) and/or employee(s) who conducted my criminal history records search and provided information to the submitting agency for any statement(s), omission(s), or infringement(s) upon my current legal rights. I further release and promise to hold harmless and covenant not to sue any persons, firms, institutions or agencies providing such information to the State of Nevada on the basis of their disclosures. I have signed this release voluntarily and of my own free will.

CONSENT TO CHECK OF REGISTRIES I consent to have a check of registries conducted, including, but not limited to, any government abuse registries, licensing registries, sexual abuse registries, the Office of Inspector General List of Excluded Individuals and Entities registry and any other registries that may be required by the Division of Public and Behavioral Health.

SELF DISCLOSURE STATEMENT OF CRIMINAL HISTORY I attest that I have never been convicted of any of the following crimes:

? Murder, voluntary manslaughter or mayhem; ? Assault or battery with intent to kill or to commit sexual assault or mayhem; ? Sexual assault, statutory sexual seduction, incest, lewdness or indecent exposure, or any other

sexually related crime that is punished as a felony (including felony prostitution); ? A crime involving domestic violence that is punished as a felony; ? Abuse or neglect of a child or contributory delinquency; ? Abuse, neglect, exploitation or isolation of older persons or vulnerable persons, including,

without limitation, a violation of any provision of NRS 200.5091 to NRS 200.50995, inclusive, or a law of any other jurisdiction that prohibits the same or similar conduct; ? A violation of any provision of NRS 422.450 to NRS 422.590, inclusive; or ? Any other felony involving the use or threatened use of force or violence against the victim or the use of a firearm or other deadly weapon.

I attest that I have not been convicted of any of the following crimes within the immediately preceding 7 years:

? Prostitution, solicitation, lewdness or indecent exposure, or any other sexually related crime that is punished as a misdemeanor;

Public Health: Working for a Safer and Healthier Nevada

? A crime involving domestic violence that is punished as a misdemeanor; ? A violation of any federal or state law regulating the possession, d istribution or use of any

controlled substance or any dangerous drug as defined in chapter 454 of NRS; ? A violation of any provision of law relating to the State Plan for Medicaid or a law of any other

jurisdiction that prohibits the same or similar conduct; ? A criminal offense under the laws governing Medicaid or Medicare; ? Any offense involving fraud, theft, embezzlement, burglary, robbery, fraudulent conversion or

misappropriation of property; or ? An attempt or conspiracy to commit any of the offenses listed in this Self Disclosure Statement

of Criminal History section.

CONSENT TO BE ENROLLED IN A RAP (Record of Arrests and Prosecutions) BACK SYSTEM

(optional -check only if you consent) DI understand that if l check this box, the facility, hospital, agency, program or home I am under employment/contract/service with or the Division of Public and Behavioral Health may enroll me in a RAP (Record of Arrests and Prosecutions) back system which would allow the Central Repository for Nevada Records of Criminal Hist01y to notify my employer and the Division of Public and Behavioral Health of any criminal offenses that I may be convicted of in the future.

AUTHORIZATION OF SUBMISSION OF FINGERPRINTS I authorize the submission of my fingerprints to the Central Repository for Nevada Records of Criminal History for submission to the Federal Bureau of lnvestigation for its background check report.

A reproduction of this authorization for release of information by photocopy, facsimile or similar process, shall for all purposes be as valid as the original.

In consideration for processing my application I, the undersigned, whose name and signature voluntarily appears below; do hereby and irrevocably agree to the above.

I understand that a person who willfully provides a false statement or information connected with a background investigation that would disqualify the person from employment, including without limitation, a conviction of a crime listed in NRS 449.174, is guilty of a misdemeanor. I declare under penalty of perjury that the foregoing is true and correct. Executed on:

Applicant's Name: ------------------------------(PLEASE PRINT LAST, FIRST, MIDDLE)

Address: ---------------------------

Applicant's Signature:

Date:

Submitting Agency: Division of Public and Behavioral Health Address: 727 Fairview Drive, Suite E, Carson City, NV 89701

Agency representative:

Michelle Smothers

(PLEASE PRINT LAST, FIRST, MIDDLE)

Agency representative's Signature:

Date:

Public Health: Working for a Safer and Healthier Nevada

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